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post-exposure HIV prophylaxis

Prophylaxis for HIV exposure after: 1) sexual activity 2) sexual assault 3) IV drug use for needle stick, see prophylaxis after needle stick Management: - risk of HIV transmission without prophylaxis is < 1% - probably diminished further with prophylaxis - prophylaxis must be started within 72 hours & continued for 28 days. a) tenofovir/FTC, emtricitabine + raltegravir or dolutegravir [5] - given for 4 weeks - not recommended if > 72 hours post-exposure b) other recommendations - tenofovir/FTC, either alone or with lopinavir/ritonavir - adverse effects, particularly with lopinavir/ritonavir, often lead to early treatment discontinuation - alternative: tenofovir/FTC + twice-daily raltegravir [6] - compliance with 2nd daily dose of raltegravir may be poor - MKSAP17 preferred regimen [5] c) see HIV1 infection for recommended regimens d) recommendations for transitioning from post-exposure HIV prophylaxis to HIV preexposure prophylaxis [10] - check HIV status immediately after exposure & at 4-6 weeks, 3 months, & 6 months For non-occupational exposure: - risk of HIV conversion is 1% with post-exposure prophylaxis [3] Notes: - with Simian immunodeficiency virus in Rhesus macaques, a persistent viral reservoir is established before the onset of viremia; the same is thought for HIV1 [8]

Related

pre-exposure HIV prophylaxis prophylaxis after needle stick; prophylaxis for blood-borne infection

General

prevention of HIV chemoprophylaxis

References

  1. Prescriber's Letter 12(3): 2005 Antiretroviral Postexposure Prophylaxis After Nonoccupational Exposure to HIV Detail-Document#: 210307 (subscription needed) http://www.prescribersletter.com
  2. Journal Watch 25(5):42, 2005 Smith DK, Grohskopf LA, Black RJ, Auerbach JD, Veronese F, Struble KA, Cheever L, Johnson M, Paxton LA, Onorato IM, Greenberg AE; U.S. Department of Health and Human Services. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep. 2005 Jan 21;54(RR-2):1-20. PMID: 15660015 http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm
  3. Roland ME et al, Seroconversion following nonoccupational postexposure prophylaxis against HIV Clin Infect Dis 41:1507, 2005 PMID: 16231265
  4. Paltiel AD et al HIV preexposure prophylaxis in the United States: Impact on lifetime infection risk, clinical outcomes, and cost-effectiveness. Clin Infect Dis 2009 Mar 15; 48:806. PMID: 19193111
  5. Medical Knowledge Self Assessment Program (MKSAP) 14, 17, 18. American College of Physicians, Philadelphia 2006, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  6. Mayer KH et al. Raltegravir, tenofovir DF, and emtricitabine for postexposure prophylaxis to prevent the sexual transmission of HIV: Safety, tolerability and adherence. J Acquir Immune Defic Syndr 2012 Apr 1; 59:354. PMID: 22267017
  7. Landovitz RJ, Currier JS. Clinical practice. Postexposure prophylaxis for HIV infection. N Engl J Med. 2009 Oct 29;361(18):1768-75 PMID: 19864675
  8. Whitney JB et al. Rapid seeding of the viral reservoir prior to SIV viraemia in rhesus monkeys. Nature 2014 Aug 7; 512:74 PMID: 25042999
  9. Kuhar DT, Henderson DK, Struble KA et al Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013 Sep;34(9):875-92. Erratum in: Infect Control Hosp Epidemiol. 2013 Nov;34(11):1238. Dosage error in article text. PMID: 23917901
  10. Centers for Disease Control and Prevention (CDC) Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV - United States, 2016. https://stacks.cdc.gov/view/cdc/38856 - Announcement. Updated Guidelines for Antiretroviral Postexposure Prophylaxis after Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV -United States, 2016. MMWR Morb Mortal Wkly Rep 2016;65:458 http://www.cdc.gov/mmwr/volumes/65/wr/mm6517a5.htm
  11. Centers for Disease Control and Prevention. HIV among women U.S. Public Health Service, U.S. Department of Health and Human Services; Nov 17, 2017. https://www.cdc.gov/hiv/group/gender/women/index.html